PROJECT SUMMARY There are a myriad of strategies claimed to reduce hospital falls, but there is little evidence supporting their use, and a recent quantitative review found no evidence of benefit among published hospital fall prevention studies using concurrent controls. Given significant financial pressure, hospitals are seeking a ?silver bullet? to fall prevention, and are all over the board in utilizing costly, unproven, and labor-intensive approaches to fall prevention. Paradoxically, these practices may add to the cognitive burden of patient care and increase patient risk. Understanding and minimizing variation is a useful tool for improving health care quality, but has not been applied to hospital falls. In this proposed study we will continue our 5 year collaboration with the National Database of Nursing Quality Indicators (NDNQI), a research and quality improvement group that trains its ~2000 participating U.S. hospitals to collect and report nurse-sensitive quality indicators and staffing data in a standardized format. In our preparatory work, we identified NDNQI adult medical nursing units with 24 month high- (~7 falls /1000 patient-days) and low- (~2 falls/1000 patient-days) fall rates. The proposed research will extend NDNQI data collection to focus specifically on patient- and organization-level fall prevention strategies on high- and low- performing units. Aim 1: Compare patient-level approaches to fall prevention employed in high- and low- fall units. We will extend NDNQI patient-level data collection to ascertain: (1) device, and (2) vigilance and (3) environmental modification strategies and compare their use, adjusting for patient-level risk, on these units. Aim 2: Explore differences in organization-level approaches to fall prevention employed in high- and low-fall units. We will extend NDNQI organization-level data collection to compare: (1) fall prevention resources, (2) labor quality and quantity, and (3) fall safety culture between high- and low fall units.